Cornwall and the Isles of Scilly

Coroner Area
Reports: 137 Earliest: Oct 2013 Latest: 16 Feb 2026

81% response rate (above 63% average).

Clear 98 results
Lugh Baker
All Responded
2023-0090Deceased 13 Mar 2023
Bowden Derra Park Ltd
Care Home Health related deaths
Concerns summary (AI summary) The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was no clear policy or training for staff to address residents with unusual presentations.
Action Taken (AI summary) The facility has updated its Nocturnal CCTV Monitoring Chart to include a comments box for explaining gaps in monitoring. They have also updated their Care Plan and Training policies, with staff notified and tracked via the BrightHR application.
Sharon Harman
All Responded
2023-0072Deceased 24 Feb 2023
Minister of State for Crime, Policing a…
Other related deaths
Concerns summary (AI summary) Police guidance for pre-release checks in domestic abuse cases was not fully applied, and officers felt they lacked legal power to retain a suspect's house key.
Action Planned (AI summary) The Home Office will raise discrepancies between College of Policing guidance and PACE powers with the College of Policing. They describe plans for Domestic Abuse Protection Notices and Orders, and reference the Tackling Domestic Abuse Plan.
James Parsons
All Responded
2023-0069Deceased 22 Feb 2023
Cornwall Council, Porthleven Harbour & …
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip hazards, and a lack of escape provisions for anyone falling into the water.
Noted (AI summary) Cornwall Council is awaiting a response from the Porthleven Food Festival event organiser regarding additional safety measures. The council will also write to all harbours and event organisers for events near harbours, making them aware of the incident and asking them to consider harbour edges as part of their risk assessment process, to be completed by the end of April 2023. The HSE clarifies its regulatory remit regarding Porthleven Harbour, stating it only applies where a work activity is taking place. It states that vires in relation to festivals and other public events falls to the Local Authority, in this case the licensing arm of Cornwall Council and their Environmental Health Office (EHO). The HSE will visit to review the health and safety arrangements at the commercial crabbing area. Porthleven Harbour & Dock Company expresses condolences and states that the Porthleven Food Festival is responsible for all health and safety matters. They state that there is no evidence of where the deceased fell into the water or that he fell at all and that the report does not point to failure of the Harbour & Dock Company to recognise potential public danger. They are committed to ongoing reviews of health and safety issues.
Daniel Tilley
All Responded
2022-0393 6 Dec 2022
Devon and Cornwall Constabulary
Suicide (from 2015)
Concerns summary (AI summary) Insufficient funding and staffing within police Communication and Control Units, compounded by inadequate officer numbers, consistently prevent timely responses to incidents, a long-standing issue particularly acute during peak demand.
Noted (AI summary) The Home Office acknowledges the coroner's concerns and outlines the government's commitment to providing resources to the police, including increasing officer numbers and funding for Devon and Cornwall Police. They also mention plans to introduce a new police funding formula. Devon and Cornwall Police detailed actions taken to address staffing and workload challenges in their CMCUs, including improvements in demand response times, implementation of wellbeing initiatives for personnel, and a process for recording and implementing learning from each summer period.
Tina Allen
All Responded
2022-0391 5 Dec 2022
Home Farm Trust Limited
Care Home Health related deaths
Concerns summary (AI summary) Persistent understaffing at the care home severely compromises the safe provision of care and treatment, and hinders effective management oversight of care quality.
Action Taken (AI summary) HFT has made improvements to service provision at Valley View, commissioning an independent review and working with stakeholders. They have increased staffing levels, provided training on specific health conditions, implemented a new digital care planning system, and enhanced the Quality Assurance Framework.
David Morganti, Winnie Barnes, Robert Conybeare and Anthony Reedman
All Responded
2022-0359 10 Nov 2022
Department of Health and Social Care
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Systemic delays in discharging medically fit patients from hospital are caused by insufficient intermediate care capacity. Discharging patients to understaffed residential homes results in patient deterioration and re-admissions, exacerbating hospital pressures.
Action Planned (AI summary) Cornwall Council has commissioned additional capacity at the Frances Bolitho care home, creating 33 new residential and nursing dementia beds and entered into a partnership with Sanctuary Housing Association. Cornwall Council has relaunched the proud to care Cornwall recruitment campaign to support providers with their recruitment of care staff. The Department of Health and Social Care is addressing concerns raised by the coroner through national initiatives, including the Urgent and Emergency Care Services Recovery Plan, which aims to reduce A&E and ambulance wait times. The Government's Primary Care Recovery Plan, currently being drafted, will respond to the challenges facing general practice.
Harry Evans
All Responded
2022-0353 4 Nov 2022
Exeter University
Suicide (from 2015)
Concerns summary (AI summary) The university lacked mandatory mental health and suicide prevention training for staff, employed an overly reactive, email-based approach to welfare concerns, and had staff unaware of information-sharing policies. Pastoral support was also limited by a lack of direct contact protocols.
Action Planned (AI summary) The University of Exeter has reviewed mental health awareness training, consolidating courses and clarifying attendance. They are also progressing replacement of the CMS, through the procurement of a new case management product, with implementation aimed for the 2023/24 academic year, and have introduced a welfare tracker to track case progress.
Paul Welch
All Responded
2022-0178 15 Jun 2022
Cornwall Council and Mylor Parish Counc…
Other related deaths
Concerns summary (AI summary) Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a tragic death.
Action Planned (AI summary) Planning and Housing Cornwall Council is expediting the application for tree works, including internal consultations, with a decision expected before the end of the month; they have also scheduled a meeting for consultation. Sailors Creek CIC hand-delivered letters, posted safety notices, removed mooring ropes from trees, held a site meeting with concerned parties, and adapted their risk assessment and safety brief. They have also implemented a temporary system for positioning moored boats further into the creek, and plan to replant trees and develop a tree management plan by the end of September 2022, and complete the mooring chain along the length of the beach by the end of 2022.
Ryan Taylor
All Responded
2022-0418Deceased 25 May 2022
Cormac and Cornwall Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning incidents that could be prevented by feasible improvements.
Action Taken (AI summary) Cormac and Cornwall Council report that they have completed significant drainage improvements in the area of the accident, including installing nearly 500m of combined kerb drainage and increasing the capacity of over 400m of underlying carrier drains.
Laura Smallwood
All Responded
2022-0109 7 Apr 2022
Minister for Crime and Policing
Other related deaths
Concerns summary (AI summary) The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities lack legal powers to mandate an organiser or refuse unsafe events.
Noted (AI summary) The Home Office acknowledges the concerns raised, explains the existing legislative framework, and states that it prefers to encourage sensible planning rather than mandating every element of it through legislation, pointing to guidance from the Cabinet Office.
Jake Cahill
All Responded
2022-0032 1 Feb 2022
Youth Justice Board for England and Wal…
Child Death (from 2015) Other related deaths Suicide (from 2015)
Concerns summary (AI summary) Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
Action Taken (AI summary) The Youth Justice Board has updated national guidance to support practitioners in using self-assessment tools appropriately when engaging with children. The updated guidance covers topics such as bail, custody, family and health.
Coco Bradford
All Responded
2022-0012 18 Jan 2022
National Institute for Health & Care Ex…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.
Action Planned (AI summary) NICE acknowledges the guideline on gastroenteritis in under 5s [CG84] does not align with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support, and has forwarded the report to their guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.
Emma Burbury
All Responded
2021-0382 11 Nov 2021
Cornwall Council Kernow Clinical Commissioning Group
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.
Action Planned (AI summary) The Trust is contributing to the implementation of a system-wide Dual Diagnosis policy and will explore improvements to information sharing between partner organisations. Community Mental Health transformation work is underway to address collaborative working between the ICMHT and other partners. NHS Kernow will provide funding for read-only access to We Are With You (WAWY) notes for CMHT staff at CFT. They are engaging with CFT regarding discharge processes and will ensure WAWY staff complete specific training modules.
Kirsty Doodes
All Responded
2021-0343 14 Oct 2021
Cornwall Partnership (Foundation) Trust
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed the patient to significant risk.
Action Planned (AI summary) The Trust is taking measures to expand the mental health workforce, including international nurse recruitment, increasing apprentice roles, and improving staff retention.
Ryan Taylor
All Responded
2021-0176 25 May 2021
Cornwall Council and CORMAC
Road (Highways Safety) related deaths
Concerns summary (AI summary) Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements have not yet been implemented despite a previous incident.
Action Planned (AI summary) Cornwall Council will erect signs warning of surface water, replace gully grids with larger capacity gratings in October, and undertake detailed drainage and topographical surveys. Further upgrades to the drainage system may be designed and implemented after the survey information is obtained.
Helen Spicer
All Responded
2021-0127 7 May 2021
Chair of the Advisory Council on the Mi…
Alcohol, drug and medication related deaths Community health care and emergency services related deaths
Concerns summary (AI summary) Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about opioid overuse and misuse. They outline actions taken, including a PHE evidence review, front-of-pack warnings on opioid medications, and structured medication reviews in primary care. The ACMD acknowledges the concerns and will gather more information on the scale of the issue of morphine sulfate solution misuse, being mindful of its legitimate use. They will request information from DHSC and NHS-E&I regarding patient safety incidents.
Caitlin Swan
All Responded
2021-0121 27 Apr 2021
CORMAC – Cornwall Council – Highways De…
Road (Highways Safety) related deaths
Concerns summary (AI summary) A concealed road junction on a downhill stretch lacks warning signs, posing a significant hazard to drivers unfamiliar with the acute turn and stationary vehicles.
Action Planned (AI summary) Cornwall Council will erect additional warning signs at the Trebost junction at Tubbon Hill, following the coroner's recommendation.
Katie Corrigan
All Responded
2021-0045 17 Feb 2021
Primary Medical Services and Integrated…
Alcohol, drug and medication related deaths Other related deaths
Concerns summary (AI summary) There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.
Action Planned (AI summary) CQC has inspected registered online providers identified from the inquest and taken regulatory action where needed. They are investigating unregistered providers and are exploring ways to strengthen regulation of online prescribers, working with other regulators and government organizations to address current and emerging threats. The Department of Health and Social Care is working with healthcare and professional regulators to strengthen the regulation of independent online prescribers. NHS England and Improvement are implementing recommendations from a review focusing on medicines associated with dependence, including structured medication reviews for patients.
Aaron Lauder
All Responded
2021-0021
Cornwall Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The primary cause of the collision was an obstructed view for both drivers at the accident site.
Action Planned (AI summary) Cornwall Council has agreed to fund a scheme to improve visibility at the farm access, with Cormac's Safety Engineering team having begun the design process and work planned for autumn.
Darrell Sharples
All Responded
2020-0219 28 Oct 2020
Devon and Cornwall Constabulary Kernow Clinical Commissioning Group
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.
Action Planned (AI summary) The Trust has introduced a 24-hour response telephone line and is developing an Initial Response Service (single point of access for people presenting with mental distress). All new staff members are required to attend a corporate welcome day induction and complete statutory training depending on their role. A former Police Superintendent has been recruited as Mental Health Liaison Officer. A trigger process to identify escalating risk in adults has been launched, including a more focused letter to GPs, with draft letter to be subject to a process of consultation. The Trust launched the Initial Response Service as a single point of access for people in mental distress. A standardised triage tool has been developed for adult mental health services throughout the Trust, and the Trust is involved in a national project to improve access to patient information.
Avis Addison
All Responded
2020-0216 14 Oct 2020
Care Quality Commission
Other related deaths
Concerns summary (AI summary) Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
Action Taken (AI summary) Following the regulation 28 notice, CQC contacted the registered person of the GP practice, and were assured about the management of safeguarding and vulnerable patients; learning from the inquest will be shared with inspectors.
Anthony Williamson
All Responded
2020-0153 7 Aug 2020
Maritime Coastguard Agency Royal National Lifeboat Institution
Other related deaths
Concerns summary (AI summary) Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available to the public.
Noted (AI summary) The MCA confirms its search and rescue services were maintained during the pandemic, describes collaboration with Surf Life Saving GB, and states responsibility for beach safety lies with landowners. The RNLI details the impact of Covid-19 on its lifeguard service, outlines its role in beach safety, and describes a joint publicity campaign with HM Coastguard and co-authored guidance for local authorities.
Jan Klempar
All Responded
2020-0152 7 Aug 2020
Maritime Coastguard Agency Royal National Lifeboat Institution
Other related deaths
Concerns summary (AI summary) Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, increasing safety risks for bathers.
Noted (AI summary) The MCA outlines its role in coordinating search and rescue missions, clarifies it has no responsibility for beach lifeguards, and describes publicity campaigns with the RNLI to encourage personal responsibility for safety. The RNLI details the impact of Covid-19 on its lifeguard service, outlines its role in beach safety, and describes a joint publicity campaign with HM Coastguard and co-authored guidance for local authorities.
Michael Pender
All Responded
2020-0122 28 May 2020
Department for Transport Maritime and Coastguard Agency Royal National Lifeboat Institute
Other related deaths
Concerns summary (AI summary) The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Noted (AI summary) The RNLI is revising plans to provide lifeguard cover on additional beaches, working with landowners and councils to confirm beaches and timings for public announcement. The MCA is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response. The MCA reiterates its role in coordinating search and rescue, clarifies that it has no statutory responsibility for beach safety, and states that it will continue to work with partners on safety campaigns.
Gillian Davey
All Responded
2020-0121 28 May 2020
Department for Transport Maritime and Coastguard Agency Royal National Lifeboat Institute
Other related deaths
Concerns summary (AI summary) The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Noted (AI summary) The RNLI is revising plans to increase lifeguard cover on beaches, working with landowners and councils to confirm beaches and timings, with public announcements to follow. The MCA is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response. The MCA states they have no statutory responsibilities for beach safety, but continue to work with partners on safety campaigns, including a joint campaign with the RNLI; they are ready to support the inquests.